Development and testing of a cancer appetite and symptom questionnaire.

BACKGROUND: Poor appetite and weight loss are common in patients with cancer, contributing to an increase in morbidity and mortality. Early identification of those at greatest risk is problematic. The Council on Nutrition Appetite Questionnaire (CNAQ) is short and easy to use, although it is not specific to cancer populations. The present study aimed to build on the CNAQ to develop a cancer appetite and symptom questionnaire (CASQ) for predicting weight loss in patients with cancer. METHODS: The content validity of the CNAQ was assessed by an expert panel (n = 41) using the content validity index (CVI). The resulting CASQ was tested for reliability among patients receiving radiotherapy (n = 34). Predictive validity of the CASQ was determined in patients with lung or upper gastrointestinal cancer (n = 185), comparing CASQ scores (possible range 0-48) recorded at baseline with percentage weight change after 12 weeks. RESULTS: In all but one CNAQ item, the CVI was above the minimum level of agreement (>0.70). Comments from expert panel members led to minor modifications and the introduction of new items resulting in the 12-item CASQ. The intraclass correlation coefficient of the CASQ was 0.80 [95% confidence interval (CI) = 0.68-0.92] and the difference between total scores at two time points was -0.20 (95% CI = -1.21 to 0.80). The optimum cut-off point of the instrument to predict >10% weight loss was 29/30 (area under curve = 0.75; sensitivity 71%, specificity 66%, positive predictive value 19%, negative predictive value 95%) [Correction added on 30 April 2012, after first online publication: in the preceding sentence, <10% was corrected to >10%]. CONCLUSIONS: The CASQ can predict weight loss among patients with lung and upper gastrointestinal cancer. Acknowledgment of the low positive predictive value is needed if the instrument is to be used within clinical practice.

Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup.

Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future 'between study' comparisons. Discussion of the physiology of breathlessness is included.

Mirtazapine for chronic breathlessness? A review of mechanistic insights and therapeutic potential.

INTRODUCTION: Chronic breathlessness is a common and distressing symptom of advanced disease with few effective treatments. Central nervous system mechanisms are important in respiratory sensation and control. Consequently, drugs which may modify processing and perception of afferent information in the brain may have a role. Antidepressants have been proposed; however, current evidence is limited. Of potentially suitable antidepressants, mirtazapine is an attractive option given its tolerability profile, low cost, and wide availability, along with additional potential benefits. Areas covered: The paper provides an overview of the physiology of breathlessness, with an emphasis on central mechanisms, particularly the role of fear circuits and the associated neurotransmitters. It provides a potential rationale for how mirtazapine may improve chronic breathlessness and quality of life in patients with advanced disease. The evidence was identified by a literature search performed in PubMed through to October 2018. Expert opinion: Currently, there is insufficient evidence to support the routine use of antidepressants for chronic breathlessness in advanced disease. Mirtazapine is a promising candidate to pursue, with definitive randomized controlled trials required to determine its efficacy and safety in this setting.

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer.

BACKGROUND: Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available. METHOD: Patients with primary or secondary lung cancer and a Dyspnoea Exertion Scale score of >or=3 were recruited. Following familiarisation, patients received either nebulised furosemide 40 mg or nebulised 0.9% saline under double blind conditions or no treatment, in random order on 3 consecutive days. Patients undertook number reading and arm exercise tests to assess breathlessness and its impact, and were asked to report subjective benefit and any preference between nebulised treatments. RESULTS: 15 patients took part. There were no differences between furosemide, saline and no treatment in the outcomes of the number reading test (eg, mean number read per breath was 6.7, 6.4 and 6.7, respectively) or arm exercise test (eg, mean Borg score at maximum equivalent workload was 2.3, 2.5 and 2.7, respectively). No adverse effects were reported, although there was a small fall in forced expiratory volume in 1 s and forced vital capacity following saline. Six patients considered that their breathlessness improved with nebulised treatment, three preferring saline, one furosemide and two reporting they were of equal benefit. CONCLUSIONS: Our findings do not support a beneficial effect from nebulised furosemide in patients with cancer related breathlessness. Listed on the National Research Register (N0170118249) and the UK Clinical Research Network Portfolio Database (1428).

A comparison of the properties of Klebsiella strains isolated from different sources.

The ability to form gas in lactose bile-salt broth at 44.5 degrees C (the "faecal coliform" or FC test), growth in nutrient broth at 10 degrees C, indole production and pectin liquefaction were studied in 480 strains of Klebsiella isolated from human and animal infections, from various sites in the hospital environment and hospital food, and from river water and flowers. A positive FC response was correlated inversely with the ability to grow at 10 degrees C. Most strains of human and animal clinical origin were FC positive, whereas strains from water and flowers were mainly FC negative. The frequency of a positive FC response in strains from the hospital environment fell between these two extremes. The production of indole and liquefaction of pectin by klebsiellas was correlated directly with the ability to grow at 10 degrees C and a negative FC response. Nearly all of the strains could be allocated to one of four groups on the basis of these tests. The capsular serotype, bacteriocine-inhibition patterns and antibiotic sensitivities of the strains were examined. No correlation was evident between the first two properties and klebsiellas from any particular source. Strains of clinical origin were more often resistant to five or more antibiotics than were strains from the hospital environment, which in turn showed a greater frequency of antibiotic resistance than did strains from river water and flowers.

Midazolam for intractable hiccup.

We describe two terminally ill cancer patients severely distressed by intractable hiccup. Commonly recommended treatments were ineffective. Intravenous midazolam 5-10 mg rapidly relieved the hiccup. Maintenance treatment comprised midazolam 40-120 mg/24 hr by continuous subcutaneous infusion.

The safety and efficacy of a single dose (500 mg or 1 g) of intravenous magnesium sulfate in neuropathic pain poorly responsive to strong opioid analgesics in patients with cancer.

Neuropathic pain may respond poorly to morphine and is often difficult to relieve. Recent attention has been drawn to the role of the N-methyl-D-aspartate (NMDA) receptor in the potentiation of neuropathic pain. Magnesium is known to block the NMDA receptor. It reduces the neuropathic pain response in animals, and attenuates postoperative pain and migraine in humans. We have examined the safety, tolerability, and efficacy of two intravenous doses of magnesium sulfate in 12 patients with neuropathic pain due to malignant infiltration of the brachial or lumbosacral plexus. The first six patients received 500 mg, the remainder 1 g. Apart from a mild feeling of warmth at the time of the injection, both doses were well tolerated. After receiving 500 mg, three patients experienced complete pain relief and two experienced partial pain relief for up to 4 hours duration; pain was unchanged in one patient. After receiving 1 g, one patient experienced complete relief and four experienced partial pain relief of similar duration; pain was unchanged in one patient. Intravenous magnesium sulfate in these doses appears to be safe and well tolerated. A useful analgesic effect may be obtained in some patients and further evaluation is warranted.

Audit of cancer pain management in a cancer centre.

Despite the availability of effective methods of controlling pain, many patients continue to receive inadequate pain relief. An audit was carried out on a single day to identify the prevalence, severity and management of cancer pain in adults in the two teaching hospitals in the Nottingham Cancer Centre. Of 186 patients with cancer, 52 had experienced pain as a result of their cancer during their admission. Of these 52 patients, 47 were assessed. More than half had unrelieved pain that was 'severe' at it s worst and interfered greatly with activities. Compared with patients whose pain had been relieved, patients with uncontrolled pain were likely to have spent less time in hospital, to have not had a formal assessment or reassessment of their pain and not to have a pain-care plan in the nursing notes or to have been seen by the hospital specialist palliative care team. We use our results to highlight areas of good practice, to identify where improvements could be made, and to inform the development of local standards and future audits.

Applied materials engineering for orthodontic wires.

In Australia, the history of materials engineering for orthodontic wires is generally related to the development of the Begg appliance. Therefore, until recently, it has helped in the search for light resilient forces produced by fine high-tensile stainless steel wires. Recently there has been added the desire to include wires of a low modulus of elasticity which also produce light forces but in larger diameter rectangular wires. There have been three periods of development, namely, up to and including the Second World War, up to Dr Begg's passing, and subsequently. A general metallurgical background for archwire selection and use is given including the following considerations: stiffness, flexibility, zero stress relaxation, formability, resiliency, high yield phenomena, and wire fracture and crack propagation; and how some of these may be evaluated by the fingers.

Cultural relativism: occupation and independence reconsidered.

In this article, findings from a qualitative study of a cohort of occupational therapy students in Auckland, New Zealand are presented. The study focussed on the experiences of students as they learned to work with people from different social and cultural backgrounds over a 3-year period. As well as identifying curriculum and teaching/learning processes that enhance intercultural competence development, the data that emerged from the study also highlight important issues about how occupation and independence are conceptualised across cultures. A review of the trans-disciplinary and occupational therapy literature dealing with theoretical, conceptual and educational issues relating to cross-cultural practice is followed by a presentation of narrative extracts that address the key concepts of occupation and independence. These are then discussed with reference to relevant occupational therapy literature. In conclusion, implications for future research and practice are explored focussing on a need for occupation and independence to be reconsidered as culturally relative constructions.

Mass casualty incident at Hospital Squadron Sipovo, Bosnia following a Czech hip helicopter crash, 8 Jan 1998.

On Thursday 8 January 1998, a Czech Hip helicopter with 21 personnel on board crashed shortly after take off from Bos Krupa, northwest Bosnia. Seventeen casualties (including six with severe injuries) were airlifted from the scene for treatment at the British Hospital Squadron in Sipovo before aeromedical evacuation the next day to Prague, or discharge to their unit. This was the largest mass casualty incident dealt with by the British Defence Medical Services since British troops deployed to Bosnia in 1992.